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• • o ter.. <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />FACILITY INFORMATION <br />BUSINESS OWNER/OPERATOR IDENTIFICATION, PAGE 2 <br />LOCALLY COLLECTED INFORMATION <br />TYPE OF ® Single Owner ❑ Corporation ❑ Partnership 17NO <br />TAFFFD SITE NETWORK <br />139 <br />nnn_ A wrry A m nw, <br />AiifiFSSOR PARCRI.NDMRFR 140 <br />NEAREST CROSS STREET <br />141 <br />005-170-07 <br />JAHANT RD. <br />PROPERTY OWNER NAME (If different from Business Owner) 142 <br />PHONE NO. <br />143 <br />ROBERT KUPKA <br />209-369-9126 <br />PROPERTY OWNER STREET ADDRESS 144 <br />PROPERTY OWNER CITY 145 <br />STATE 146 <br />ZIP CODE <br />141 <br />P. O. DRAWER 10 <br />ACAMPO <br />CA <br />95220 <br />FIRE DISTRICT NAME 14 <br />FIRE DEPT NO. 14 <br />FACILITY LOCK BOX 15 <br />IF YES, WHERE IS IT LOCATED? <br />151 <br />WOODBRIDGE <br />UNION <br />iaavn. <br />NO <br />WATT FRF nF Rl FSINPSS <br />152 <br />AIRCRAFT MAINTENANCE AND REPAIR <br />WASTE GENERATOR 153 <br />IF YES. ENTER EPA NUMBER <br />154 <br />YES <br />CAL000349912 <br />TR AnF. RFCRPT INFORMAT1nN 155 <br />SPILL PREVENTION AND COTFNTFRMEASURES PLAN PREPARED FOR FACILITY? <br />156 <br />NO <br />YES <br />TRA I ING PROGRAM INFORMATION <br />157 <br />.,,...,...,,.._ �....:_.._.. ,........._ ..__,,,...._ ....:_:.... __-.._......,....:_..,..a...:_:.:.., «..:_:_,..._a ..__...., ._�....,.....,.o YES <br />Does your business maintain written training records that show the training subject, date(s) of training, YES <br />RLi.i.tNr AnnRHRR if diffrrnnf &nm Main-- Addroae. nth—i— Im. hlnn4 <br />BUSINESS BILLING ADDRESS <br />158 <br />BUSINESS BILLING CITY 159 <br />STATE 160 <br />ZIP CODE <br />161 <br />This area intentionally left blank <br />